Penetrating Intraperitoneal Colon Injuries, Management of
Citation: J Trauma. 86(3):505-515, Mar 2019
A meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma
Cullinane, Daniel C., MD; Jawa, Randeep S., MD; Como, John J., MD, MPH; Moore, Ashlee E., MD; Morris, David S., MD; Cheriyan, Jerry, MD; Guillamondegui, Oscar D., MD; Goldberg, Stephanie R., MD; Petrey, Laura, MD; Schaefer, Gregory P., DO; Khwaja, Kosar A., MD; Rowell, Susan E., MD; Barbosa, Ronald R., MD; Bass, Gary A., MD, MSc; Kasotakis, George, MD, MPH; Robinson, Bryce R.H., MD, MS
From the Department of Surgery, Marshfield Clinic, Marshfield, Wisconsin (D.C.C.); Division of Trauma, Stony Brook University School of Medicine, Stony Brook, New York (R.S.J.); Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio (J.J.C.); Department of Surgery, Holmes Medical Center, Melbourne, Florida (A.M.); Department of Surgery, Intermountain Health Care, Murray, Utah (D.S.M.); Department of Surgery, Kern Medical Center, Bakersfield, California (J.C.); Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee (O.D.G.); Department of Surgery, Virginia Commonwealth University, Richmond, Virginia (S.R.G.); Department of Surgery, Baylor University Medical Center, Dallas, Texas (L.P.); Department of Surgery, West Virginia University Medical Center, Morgantown, West Virginia (G.S.); Department of Surgery, Montreal General Hospital, Montreal, Quebec, Canada (K.A.K.); Department of Surgery, Oregon Health & Science University, Portland, Oregon (S.E.R.); Department of Surgery, Legacy Emmanuel Medical Center, Portland, Oregon (R.R.B.); Department of Surgery, St. Vincent's Hospital, Dublin, Ireland (G.A.B.); Department of Surgery, Boston Medical Center, Boston, Massachusetts (G.K.); and Department of Surgery, University of Washington, Seattle, Washington (B.R.H.R.).
Submitted: June 20, 2018, Revised: July 11, 2018, Accepted: November 11, 2018, Published online: November 21, 2018.
Address for reprints: Daniel C. Cullinane, MD, Marshfield Clinic, 1000 N Oak Avenue, Marshfield, WI 54449; email: email@example.com.
This manuscript was not presented at any meeting or conference.
BACKGROUND The management of penetrating colon injuries in civilians has evolved over the last four decades. The objectives of this meta-analysis are to evaluate the current treatment regimens available for penetrating colon injuries and assess the role of anastomosis in damage control surgeryto develop a practice management guideline for surgeons.
METHODS Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines section of EAST conducted a systematic review using MEDLINE and EMBASE articles from 1980 through 2017. We developed three relevant problem, intervention, comparison, and outcome (PICO) questions regarding penetrating colon injuries. Outcomes of interest included mortality and infectious abdominal complications.
RESULTS Thirty-seven studies were identified for analysis, of which 16 met criteria for quantitative meta-analysis and included 705 patients considered low-risk in six prospective randomized studies. Seven hundred thirty-eight patients in 10 studies undergoing damage control laparotomy and repair or resection and anastomosis (R&A) were included in a separate meta-analysis. Meta-analysis of high-risk patients undergoing repair or R&A was not feasible due to inadequate data.
CONCLUSIONS In adult civilian patients sustaining penetrating colon injury without signs of shock, significant hemorrhage, severe contamination, or delay to surgical intervention we recommend that colon repair or R&A be performed rather than routine colostomy. In adult high-risk civilian trauma patients sustaining penetrating colon injury, we conditionally recommend that colon repair or R&A be performed rather than routine colostomy. In adult civilian trauma patients sustaining penetrating colon injury who had damage control laparotomy, we conditionally recommend that routine colostomy not be performed; instead, definitive repair or delayed R&A or anastomosis at initial operation should be performed rather than routine colostomy.
LEVEL OF EVIDENCE Systematic review/meta-analysis, level III.
Management of penetrating colon wounds has evolved over the past four decades as primary repair has become commonplace. Traditionally, most colon injuries in the civilian population were managed by colostomy. Since the publication of several prospective randomized studies (PRS) on the subject[3–7] and Eastern Association for the Surgery of Trauma (EAST) 1998 Guidelines for the Management of Penetrating Colon Injury, there has been increasing experience with colon injury repair at time of intervention. Repair avoids colostomy and its associated psychosocial stigmata, reduces morbidity from the colostomy itself (25%), and obviates the costs and high complication rates associated with colostomy closure.[11–15]
In 1998, EAST published a practice management guideline (PMG) for the management of penetrating colon injuries. At the time, most trauma surgeons were likely to perform repair even with significant contamination. Since this publication, larger observational studies have been reported, more patients are having resection and anastomosis (R&A), and newer techniques are being used including delayed anastomosis (DA) after damage control laparotomy (DCL) and increased implementation of resuscitation strategies limiting crystalloid use. Therefore, we have performed a systematic review and meta-analysis to develop updated evidence-based recommendations for the management of penetrating colon injuries in the adult civilian population.
This guideline has been developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework.[18–20] Three specific problem, intervention, comparison, and outcome (PICO) questions were addressed:
- PICO Question 1: For low-risk adult civilian patients with penetrating abdominal trauma, should colon repair/R&A be performed versus colostomy to improve survival and reduce infectious complications?
- PICO Question 2: For high-risk adult civilian patients with penetrating colon injury, should colon repair/R&A be performed versus colostomy to improve survival and reduce infectious complications?
- PICO Question 3: For high-risk adult civilian patients requiring DCL, should repair/R&A of penetrating/blunt colon injuries be performed versus colostomy to improve survival and reduce infectious complications?
Outcomes were chosen and rated in importance from 1 to 9, with scores from 7 to 9 representing critical outcomes. Following the Delphi consensus, mortality, anastomotic leak, and infections were considered critical outcomes. Infectious complications were defined as superficial surgical site infection, deep surgical site infection, abscess, fistula, anastomotic leak, and fascial dehiscence.
With the assistance of a medical librarian, a computerized search of the National Library of Medicine, PubMed, Cochrane, and Embase databases was undertaken on April 2, 2017. English-language citations were included for the period of January 1, 1980, through April 2, 2017, using key words “colon injury,” “colon trauma,” “colon repair,” “damage control,” and “penetrating abdominal trauma.”.
Review articles and case reports were excluded from examination. Studies not directly addressing penetrating colon injury, rectal injuries, and/or articles only addressing blunt colonic trauma and military-related injuries were also excluded. Of 1,055 articles identified, 37 studies were included (Fig. 1). Randomized trials, prospective and retrospective cohort studies, and case series with outcomes analyses were used to establish recommendations. These reports were categorized by quality of study design and graded according to Guyatt et al. Articles were compiled by the committee chair. All selected articles were reviewed by at least two committee members.
Forest plots were generated and treatment effects calculated for each outcome with each study weighed proportionally to the number of subjects contributed to the analysis. Heterogeneity was calculated using χ(Cochran Q statistic) and quantified with I . I  values of less than 25% were considered to provide a low degree of heterogeneity; I  values in the 25% to 50% range were moderately heterogeneous, and values greater than 50% were indicative of high heterogeneity.
Publication bias was evaluated using the Egger test; meta-analyses were performed using STATA 15 (Stata, College Station, TX).
The GRADE framework describes four levels of evidence quality: high, moderate, low, and very low.[24–40]Recommendations were based on the overall quality of evidence including a risk-benefit ratio that included patients' values and preferences. Strong recommendations are prefaced by the statement, “we recommend.” Weak recommendations are prefaced by the statement, “we conditionally recommend.”[28–32]
Results for Colon Repair/Resection and Anastomosis versus Routine Colostomy in Low-Risk Adult Civilian Patients Sustaining Penetrating Trauma (PICO 1)
Several studies were used to formulate the 1998 EAST PMG.[3–6] In 1979, Stone and Fabian enrolled 139 patients in a prospective randomized controlled trial (RCT) to compare repair with colostomy and demonstrated that repair was at least as safe as colostomy though high-risk patients (transfusion, delay, shock, contamination) were excluded from enrollment. Low-risk colon injuries were defined as destructive or non-destructive colon injuries without need for transfusion >6 units PRBC, delay to surgery, signs of shock or severe contamination. Chappius et al. demonstrated that septic and infectious complications, including intra-abdominal abscess, were similar between the repair and fecal diversion groups. In 1992, Falcone et al.reported outcomes in an observational study of 122 patients who underwent repair for penetrating colon injuries. At the beginning of the study, all wounds determined intra-operatively to require resection were managed with obligate end colostomy. However, midway through the study, these patients had their management changed to primary anastomosis without fecal diversion. Incidence of sepsis in this cohort was found to be similar to those treated earlier with end colostomy. In contrast, Sasaki et al. noted a higher rate of infectious complications in the colostomy group versus primary repair/R&A in a prospective RCT of 71 patients though the authors noted that some complications were attributable to colostomy reversal.
Since the 1998 EAST PMG, two additional RCTs have been published. In a follow-up study, Gonzalez et al. reported that patients treated with colostomy had higher rates of complications (abdominal abscess, wound dehiscence, enterocutaneous fistula, gangrenous stoma, peristomal abscess, or parastomal small bowel volvulus) than patients treated with primary repair. Kamwendo et al. published a trial with 238 patients randomized to repair or diversion and analyzed the effect of a delay of surgery (<12 and >12 hours) on outcomes. Patients managed with colostomy had higher rates of complications (sepsis, pulmonary complications, wound dehiscence, enterocutaneous fistula, and wound complications) regardless of surgical delay. The consensus from these trials was that primary repair of penetrating colon injuries seemed to be at least as safe as fecal diversion, if not safer.[4–7]
A 2003 Cochrane meta-analysis comparing primary repair with colostomy, in low-risk patients, demonstrated no difference in mortality between patients undergoing primary repair versus those receiving colostomy (odds ratio (OR) for mortality, 1.22; 95% confidence interval (CI), 0.4–3.74) and demonstrated a lower rate of complications in the group managed with primary repair (OR, 0.54; 95% CI, 0.39–0.76). Specifically, the primary repair group had a lower OR of infectious complications (OR, 0.44; 95% CI, 0.17–1.1), abdominal infection (OR, 0.67; 95% CI, 0.35–1.3), and wound complications (OR, 0.73; 95% CI, 0.38–1.39) although wide confidence intervals precluded statistical significance. The authors concluded that all penetrating colon injuries could be safely managed by primary repair, including R&A, and rated the evidence at Level 1B (from randomized trials). Observations from retrospective studies support the conclusion that nearly all colon injuries in low-risk patients can be successfully repaired.[44–48]
Colon Resection/Anastomosis for Destructive Injuries
In 1998, available data regarding patients with destructive colon injuries (>50% of the circumference of the colon) were scarce, and the PRS available included only a small number of patients managed with R&A.[3–7]Around the time of the 1998 EAST PMG, two additional studies demonstrated concerning complication rates in patients with destructive colon injuries. As a result, the 1998 Guideline recommended R&A for management of destructive injuries only if the patient did not have concurrent shock (systolic blood pressure (SBP) <90 mm Hg), underlying comorbid disease, significant associated injuries, penetrating abdominal trauma injury (PATI) score > 25, injury severity score (ISS) > 25, Flint grade > 11, or peritonitis. Destructive colon injuries alone do not necessarily qualify as high-risk colonic injuries.
In an effort to address the conflicting evidence, an American Association for the Surgery of Trauma (AAST) prospective multicenter trial was performed in 2001. This study included 297 patients who were treated with colon resection; 66% of patients underwent R&A and 34% were managed with colostomy. Despite including high-risk patients as defined by the 1998 Guideline, a lower mortality rate was discovered for primary anastomosis (0% versus 4%, p = 0.012), and no significant difference in complication rates (intra-abdominal abscess, colon leak, fascial dehiscence) were noted. Although the groups were well-matched, there were higher rates of shock, colon injury severity, and PATI scores in the colostomy group. The authors concluded that the surgical procedure for colon injuries did not affect mortality regardless of associated risk factors, despite some differences in the populations examined.
Quantitative Synthesis (Meta-Analysis)
Figure 2. Forest plot of mortality and infectious complications in adult low-risk trauma patients with penetrating colon injuries.
A total of 705 subjects with colon injury from six PRS were included in our analysis for PICO 1. Separating recommendations for repair versus R&A were not possible given limitations and variability of the current prospective studies. Analysis of pooled data demonstrated similar mortality between patients having repair/R&A versus colostomy (OR, 1.218; 95% CI, 0.40–3.74; p = 0.73). Regarding infections, patients having repair/R&A tended to have improved outcomes versus those who had colostomy (OR, 0.42; 95% CI, 0.17–1.03; p = 0.059). Heterogeneity was low for analysis of mortality (I  = 0.0%, p = 0.61), and high with regard to surgical infections (I  = 80.8%, p < 0.001). The data regarding mortality and infectious complications are summarized in Figure 2.
Grading the Evidence
No serious publication bias was detected for either analyzed outcome although some inconsistency was found in smaller studies. There are several prospective randomized trials that addressed this question. The overall quality of evidence is high (Table 1).
Recommendation (PICO 1)
Based on the evidence, 15 of 16 authors voted in favor of a strong recommendation for colon repair or R&A in low-risk patients. Therefore, in adult civilian patients with penetrating colon injury without signs of shock, significant hemorrhage, severe contamination, or delay to surgical intervention, we recommend that colon repair or R&A be performed rather than colostomy.
Results for Colon Repair/Resection and Anastomosis versus Routine Colostomy in High-Risk Adult Civilian Patients Sustaining Penetrating Trauma (PICO 2)
High-level recommendations cannot be provided for high-risk civilian penetrating colon injuries due to confounding variables, limited population, and few prospectively designed trials. Many studies had variable inclusion of different penetrating mechanisms, namely stab wounds, gunshot wounds, and blunt traumatic injuries, that may influence risk for infectious complications.[52–55] Furthermore, differences in intra- and post-operative management of colonic injuries can alter patient risk for complications.[56–58] However, even with these inconsistencies, some general conclusions can be made specifically that R&A has similar complication rates to colostomy in high-risk patients, and certain patient-specific factors can pre-dispose patients to infectious complications regardless of procedure.
Early PRS by Chappuis et al. and Gonzales et al. indicated that patients with high-risk factors such as shock, hypotension (SBP < 80 mm Hg), fecal contamination, or PATI scores >25 who underwent primary repair had a similar incidence of complications as patients who underwent colostomy. These results were confirmed in the 2001 American Association for the Surgery of Trauma study, as no differences in incidence of abdominal complications were noted in high-risk patients (severe fecal contamination, transfusion of >4 units blood within 24 hours, shock, delay of >6 hours to laparotomy, or PATI scores >25) who underwent R&A versus colostomy. However, in a 2015 prospective observational study by Torba et al., transfusion (OR, 1.2; 95% CI, 1.03–1.57; p = 0.02) and creation of a colostomy (OR, 9.1; 95% CI, 3.9–21.1; p < 0.001) were both independent risk factors for abdominal complications in patients with destructive colon injuries. Other factors, age, sex, mechanism of injury, hypotension, time from injury to operation, fecal contamination, colon injuryseverity, site of colon injury, associated injuries, and PATI, were not identified to be significant independent risk factors.
Retrospective analyses of various civilian trauma populations also have conflicting evidence regarding the effect of patient-specific factors in the development of postoperative complications, morbidity, and mortality. Adesanya et al. reviewed the outcomes of 60 patients who either received R&A (right side colon wounds) or colostomy (left side colon wounds) and observed no difference in outcome (morbidity/mortality) between groups although moderate or severe fecal contamination was present in 96.7% of patients, and most patients had a delay to surgery of more than 12 hours. In a larger study, 145 patients with penetrating colon injuryduring two separate time periods were reviewed. Only one primary repair failure occurred in the early period, and no failures occurred with R&A. During the later time period, a greater percentage of patients had a higher PATI score than is generally recommended for repair, yet these patients received primary repair. Patient morbidity remained at 24% regardless of procedure for both periods. No significant differences in mortality were also noted by Bulger et al. in a cohort of 186 patients who underwent primary repair/R&A (53%) versus colostomy (47%). In contrast, Sharpe et al. observed a higher overall mortality rate in patients undergoing colostomy versus R&A for destructive injuries although colon-related mortality and morbidity were not significantly different.
At first glance, patient morbidity and development of postoperative complications seem dependent on patient-specific factors. When analyzing complication rates associated with colostomy versus R&A, Sharpe et al.discovered that ISS, abdominal abbreviated injury score, and transfusion needs were significantly higher and admission SBP significantly lower in the colostomy group compared to the R&A group. Although most of these destructive colon injuries could have been repaired by R&A, colostomy was recommended for patients requiring more than 6 units of blood in the first 24 hours and/or patients with significant comorbid diseases.Similarly, Ozturk et al. recommended stoma formation for high-risk patients (defined as severe contamination, shock, and high-grade colon injury) based on overall complication rate for 141 patients with penetrating colonic injury who received primary repair, R&A, primary repair with colostomy, or colostomy/exteriorization of the injured segment although no formal subgroup analysis was performed.
However, these patient-specific associations tend to decrease in multivariate analyses. In Bulger et al., the outcomes of 186 patients with penetrating colon injuries were compared between two groups: 53% received primary repair/R&A and 47% received colostomy. While the total complication rate of patients requiring colostomy was significantly higher (57% vs 42%), when adjusting for ISS and hypotension, colostomy was not associated with a significant increase in total complication rate. Furthermore, the incidence of abdominal abscess, wound infection, wound dehiscence, and anastomotic leak were not significantly different. Subgroup analysis indicated that development of infectious complications was related to ISS and shock, not the operation performed. Dente et al. reported that PATI scores greater than 30, ISS greater than 16, transfusion of more than 2 units of blood, and a revised trauma score greater than 7.8 were all significantly associated with infections based on univariate analysis of outcomes for 311 patients with penetrating colon injuries. With multivariate logistic regression, all factors with the exception of revised trauma score had a significant association with infectious complications, and no high-risk groups were identified for whom a colostomy had fewer septic complications. The authors concluded that the presence of a colostomy was associated with a greater burden of septic abdominal complications than primary repair.Similarly, Girgin et al. were unable to identify a high-risk group where colostomy prevented septic complications. Univariate analysis indicated that gunshot wounds, delay to operation of more than 6 hours, shock, operation duration of more than 6 hours, PATI score greater than 25, ISS greater than 20, colonic ISS greater than 3, major fecal contamination, more than two extra-abdominal injuries, transfusion greater than 4 units of blood, and colostomy were significantly associated with increased morbidity. Only colostomy and transfusion remained independent factors for colon-related morbidity in subsequent multivariate regression.
Contrary to Dente et al. and Girgin et al., Durham et al. noted that presence of a colostomy was not associated with infection. No significant differences in wound or intra-abdominal complication rates were found among high-risk patients (PATI score >30 or colonic injury score (CIS) >4) undergoing primary repair versus colostomy although the abdominal trauma index and CIS were significantly higher in the colostomy group. Further evaluation of risk factors for intra-abdominal and wound complications using stepwise regression revealed that only abdominal trauma index, CIS, and gross contamination were independent predictors of complications. Therefore, repair or R&A of penetrating colon injuries should be considered in the context of patient-specific factors and colostomy may be warranted in some patients.
Quantitative Synthesis (Meta-Analysis)
Meta-analysis was not appropriate owing to heterogeneity and variability in data reporting. A summary table of available evidence for PICO 2 was created (Table 2).
Grading the Evidence
No serious publication bias was detected although some inconsistency was found in smaller studies.Although there are prospective trials (high quality) addressing this question, most of the data are retrospective (low quality). The overall quality of evidence is low (Table 1).
Recommendation (PICO 2)
Based on the evidence, 15 of 16 authors voted in favor of the following recommendation: In adult, high-risk (delay >12 hours, shock, associated injury, transfusion >6 units of blood, contamination, or left side colon injuries) trauma patients with penetrating colon injury, we conditionally recommend that colon repair or R&A be performed rather than mandatory colostomy. Colostomy may have a limited role in select patients.
Results for Colon Repair/Resection and Anastomosis versus Routine Colostomy in those Requiring DCL (PICO 3)
A question not addressed by the 1998 Guideline was the management of colon injuries in the setting of DCL. There are no prospective trials that specifically address this question, and available studies have conflicting recommendations. By definition, patients requiring DCL have high-risk physiology with expected higher rates of sepsis and anastomotic leak, which skew the data. Furthermore, surgeons are concerned about performing an anastomosis in DCL due to bowel edema and the negative pressure produced from temporary abdominal closure.
Initial studies suggested that R&A is safe to perform in the context of a DCL. Johnson et al. reported the earliest colon R&A in the setting of DCL in 2001. Since then, management of colon injuries shifted from colostomy in all surviving DCL patients to primary repair or R&A at their institution. Comparing results from the two studies, there was no statistically significant difference in abdominal septic complications. Miller et al. compared DA in DCL to R&A at initial operation. Despite more severe initial shock in the DCL group, there were no anastomotic leaks in the DA group, and abscess rate and colon-related mortality were similar in both groups. Chavarria-Aguilar et al. reviewed destructive colon injuries in DCL over an 11-year period. The incidence of intra-abdominal abscesses were not significantly different between primary colonic repairs and diverting stomas in 104 patients requiring resection (29 requiring DCL). Similarly, Ordoñez et al.reported that R&A can be safely performed with DCL in patients with colon injury. Two patients in the DA group leaked versus one in the single laparotomy (SL) group (p = 0.6), and there was one colon-related death (DCL) in this study. Combined, these studies suggest that DA during DCL is safe.
However, other studies indicate that DA with DCL is not the safest option for patients with colon trauma. Ott et al. published a cohort study of 174 trauma colon resections using both damage control and immediate abdominal closure. The authors reported an “unacceptable” leak rate with DA after DCL (27%) compared to SL (6%; p < 0.01). Unsurprisingly, the DCL group had a significantly greater length of stay (LOS), mortality, intensive care unit days, transfusion requirements, and physiologic derangement compared to the immediate repair group, as these patients were intrinsically sicker than patients receiving immediate abdominal closure. Although the consequences of leak led to more complications and longer LOS, the mortality rates were not statistically different between patients having SL and DCL. Weinberg et al. published a review of 157 patients with colon injuries requiring repair, R&A, or colostomy and compared complication rates between SL and DCL. For patients requiring R&A, the DCL group had a higher incidence of complications, and colon-related complications in the DCL group were statistically higher than those in the SL group (30% vs 12%, p < 0.01). The anastomotic leak rate was also higher in the DCL group (12% vs 3%, p < 0.05).However, only penetrating mechanism was found to be a statistically significant risk factor for complications.
The largest study to date is the Western Trauma Association's (WTA’s) multi-institutional study evaluating both small and large bowel anastomoses in the open abdomen. Sixty-five patients who had DA after DCL were included. Eighteen percent of patients with DA had postoperative leaks, and the authors noted a progressively higher leak rate as one moved distally in the colon. This study also identified risk factors associated with leak, including higher heart rate, higher base deficit at 12 hours after injury, and later time to abdomen closure, with closure after Day 5 associated with a leak rate four times higher than patients without operative delay. This group recommended a cautious approach to colon R&A in DCL. Similar to the WTA study, Kashuk et al. reported 29 patients who underwent DA after DCL; four patients developed a leak compared to one patient in the SL group (p < 0.01). There were no leaks in the four patients who had colon repair with DCL. In a small multi-center study, Tatebe et al. examined the role of DA in DCL. Although the study is underpowered, the authors found that DCL was not associated with increased enteric leaks, entercutaneous fistula, surgical site infection, or intraperitoneal abscess.
In a recent study by Anjaria et al., a higher leak rate was found in DCL patients compared to SL patients but only if the patient was unable to be closed at the first take-back operation. Similarly, the intra-abdominal abscess rate for DCL was higher than that for SL (38% vs 17%, p < 0.01) but only if the patient could not have the fascia closed on the first take-back operation. The authors concluded that DA is safe provided the fascia is closed at the first take-back; otherwise, a stoma should be created. However, they noted that multiple take-back operations are most likely a marker for a much sicker population which seems consistent with the series from the WTA and Georgoff et al., suggesting that if DA is to be performed, it should be done early. In summary, the literature indicates that R&A and DA with DCL is appropriate for certain populations.
Quantitative Synthesis (Meta-Analysis)
Figure 3. Forest plot of mortality and infectious complication rates in adult damage control surgery patients with colon injuries.
A total of 395 subjects from 10 retrospective studies were included in our analysis. Separating recommendations for repair versus R&A was not possible given limitations and variability among studies. Analysis of pooled data demonstrated similar mortality between those having repair/R&A versus colostomy (OR, 0.916; 95% CI, 0.26–3.26; p = 0.893). Regarding infections, patients undergoing repair/R&A showed a trend toward worse infectious complications versus those who had colostomy (OR, 1.593; 95% CI, 0.76–3.34; p = 0.217). Heterogeneity was high in analysis of mortality (I  = 61.3%) and low (I  = 0.0%) with regard to surgical infections, and no publication bias was evident for either outcome. A summary of the data for the outcomes is provided in Figure 3.
Grading the Evidence
No serious publication bias was detected for either outcome nor was there inconsistency, indirectness, or imprecision in the available studies. All studies addressing this question are retrospective. The overall quality of evidence is very low (Table 1).
Recommendation (PICO 3)
While there is risk in performing an anastomosis, stoma formation is also accompanied by morbidity in patients requiring DCL. The presence of a stoma can also compromise wound management and subsequent abdominal fascial closure. Nearly all available studies demonstrate that higher ISS, greater transfusion requirements, more severe physiologic derangement, and longer hospital LOS are factors for increased complication risk in DCL groups. The best outcome for DA is seen in patients who resuscitate and achieve abdominal closure earlier although the quality of evidence in this area is very low. Based on the literature, 10 authors voted in favor of a strong recommendation and six voted in favor of a conditional recommendation. Therefore, in adult trauma patients with penetrating colon injury who had DCL, we conditionally recommend that mandatory colostomy not be performed; instead, definitive repair, delayed R&A, or anastomosis (if resection already took place in the setting of DCL) may be performed rather than colostomy. Clinical judgment in these situations is paramount.
Applying this Guideline to Clinical Practice
This PMG presents qualitative and quantitative data to formulate recommendations based on available studies on the treatment of penetrating colon injury. We recognize that every situation is different and that patient, personnel, institutional, and situational factors may warrant or require deviation from our recommendations. We encourage institutions to use this PMG to formulate their own protocols for surgically managing penetrating colon injuries.
Three evidence-based recommendations have been provided for adult civilian patients with penetrating colonic trauma. In patients without signs of shock, hemorrhage, severe contamination, or delay to surgical intervention, we recommend that colon repair or R&A be performed rather than colostomy. For high-risk patients, including those receiving DCL, we conditionally recommend that colon repair or R&A be performed rather than mandatory colostomy except in patients with the most severe injuries.
DCC and RSJ designed the study and performed PICO development, literature review, data extraction, data interpretation, manuscript development, and manuscript editing. JJC and BRHR performed PICO development, literature review, data extraction, data interpretation, manuscript development, and manuscript editing. AM performed literature review, data extraction, manuscript development, and manuscript editing. DSM, and GAB performed literature review, data extraction, data interpretation, manuscript development, and manuscript editing. JC performed data extraction, data interpretation, manuscript development, and manuscript editing. ODG designed the study and performed PICO development, literature review, data extraction, data interpretation, and manuscript editing. SRG and KAK performed literature review, data extraction, and manuscript editing. LP and RRB performed PICO development, literature review, data extraction, data interpretation, manuscript editing. GS and SER performed literature review, data extraction, data interpretation, manuscript editing. GK performed PICO development, data extraction, data interpretation, manuscript development, manuscript editing.
The authors thank Emily Andreae, PhD, for assistance with manuscript editing and Brian J. Finnegan, MLIS, for assistance with the document search.
The authors declare no conflicts of interest.
No external sources of funding were used in the preparation of this manuscript.
- Mulherin JL Jr., Sawyers JL. Evaluation of three methods for managing penetrating colon injuries. J Trauma. 1975;15(7):580–587. View Full Text| PubMed| CrossRef
- Adkins RB Jr., Zirkle PK, Waterhouse G. Penetrating colon trauma. J Trauma. 1984;24(6):491–499. View Full Text| PubMed| CrossRef
- Stone HH, Fabian TC. Management of perforating colon trauma: randomization between primary closure and exteriorization. Ann Surg. 1979;190(4):430–436. View Full Text| PubMed| CrossRef
- Chappuis CW, Frey DJ, Dietzen CD, Panetta TP, Buechter KJ, Cohn I Jr. Management of penetrating colon injuries. A prospective randomized trial. Ann Surg. 1991;213(5):492–498. View Full Text| PubMed| CrossRef
- Falcone RE, Wanamaker SR, Santanello SA, Carey LC. Colorectal trauma: primary repair or anastomosis with intracolonic bypass vs. ostomy. Dis Colon Rectum. 1992;35(10):957–963. View Full Text| PubMed| CrossRef
- Sasaki LS, Allaben RD, Golwala R, Mittal VK. Primary repair of colon injuries: a prospective randomized study. J Trauma. 1995;39(5):891–901.
- Gonzalez RP, Merlotti GJ, Holevar MR. Colostomy in penetrating colon injury: Is it necessary? J Trauma. 1996;41(2):271–275. View Full Text| PubMed| CrossRef
- Cayten CG, Fabian TC, Garcia VF, Ivatury RR, Morris JA. Penetrating colon injuries, management of. J Trauma. 1998;44(6):941–956.
- Park JJ, Del Pino A, Orsay CP, Nelson RL, Pearl RK, Cintron JR, Abcarian H. Stoma complications: the Cook County hospital experience. Dis Colon Rectum. 1999;42(12):1575–1580. View Full Text| PubMed| CrossRef
- Pachter HL, Hoballah JJ, Corcoran TA, Hofstetter SR. The morbidity and financial impact of colostomy closure in trauma patients. J Trauma. 1990;30(12):1510–1513. View Full Text| PubMed| CrossRef
- Crass RA, Salbi F, Trunkey DD. Colostomy closure after colon injury: a low-morbidity procedure. J Trauma. 1987;27(11):1237–1239. View Full Text| PubMed
- Sola JE, Bender JS, Buchman TG. Morbidity and timing of colostomy closure in trauma patients. Injury. 1993;24(7):438–440. PubMed| CrossRef
- Thal ER, Yeary EC. Morbidity of colostomy closure following colonic trauma. J Trauma. 1980;20(4):287–291. View Full Text| PubMed| CrossRef
- Williams RA, Csepanyi E, Hiatt J, Wilson SE. Analysis of the morbidity, mortality, and cost of colostomy closure in traumatic compared with non-traumatic colorectal diseases. Dis Colon Rectum. 1987;30(3):164–167. View Full Text| PubMed| CrossRef
- Berne JD, Velmahos GC, Chan LS, Asensio JA, Demetriades D. The high morbidity of colostomy closure after trauma: Further support for the primary repair of colon injuries. Surgery. 1998;123(2):157–164. PubMed| CrossRef
- Eshraghi N, Mullins RJ, Mayberry JC, Brand DM, Crass RA, Trunkey DD. Surveyed opinion of American trauma surgeons in management of colon injuries. J Trauma. 1998;44(1):93–97. View Full Text| PubMed| CrossRef
- Pezim ME, Vestrup JA. Canadian attitudes toward use of primary repair in management of colon trauma. A survey of 317 members of the Canadian Association of General Surgeons. Dis Colon Rectum. 1996;39(1):40–44. View Full Text| PubMed| CrossRef
- Kerwin AJ, Haut ER, Burns JB, Como JJ, Haider A, Stassen N, Dahm P. Eastern Association for the Surgery of Trauma Practice Management Guidelines Ad Hoc Committee. The Eastern Association of the Surgery of Trauma approach to practice management guideline development using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S283–S287.
- Guyatt G, Gutterman D, Baumann MH, Addrizzo-Harris D, Hylek EM, Phillips B, Raskob G, Lewis SZ, Schünemann H. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians task force. Chest. 2006;129(1):174–181. View Full Text| PubMed| CrossRef
- Rhodes M. Practice management guidelines for trauma care: presidential address, Seventh Scientific Assembly of the Eastern Association for the Surgery of Trauma. J Trauma. 1994;37(4):635–644. View Full Text| PubMed| CrossRef
- Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–1558. PubMed| CrossRef
- Egger M, Smith G, Altman D. Systematic Reviews in Health Care: Meta-Analysis in Context. London: BMJ Books; 2011.
- Sterne JA, Egger M, Smith GD. Systematic reviews in health care: Investigating and dealing with publication and other biases in meta-analysis. BMJ. 2001;323(7304):101–105. View Full Text| PubMed| CrossRef
- Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, Schünemann HJ. GRADE Working Group. Going from evidence to recommendations. BMJ. 2008;336(7652):1049–1051. View Full Text| PubMed| CrossRef
- Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S, Falck-Ytter Y, Glasziou P, DeBeer H, et al. GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383–394. PubMed| CrossRef
- Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, Alderson P, Glasziou P, Falck-Ytter Y, Schünemann HJ. GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol. 2011;64(4):395–400. PubMed| CrossRef
- Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401–406. PubMed| CrossRef
- Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, Montori V, Akl EA, Djulbegovic B, Falck-Ytter Y, et al. GRADE guidelines: 4. Rating the quality of evidence - study limitations (risk of bias). J Clin Epidemiol. 2011;64(4):407–415. PubMed| CrossRef
- Guyatt GH, Oxman AD, Montori V, Vist G, Kunz R, Brozek J, Alonso-Coello P, Djulbegovic B, Atkins D, Falck-Ytter Y, et al. GRADE guidelines: 5. Rating the quality of evidence—publication bias. J Clin Epidemiol. 2011;64(12):1277–1282. PubMed| CrossRef
- Guyatt GH, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D, Devereaux PJ, Montori VM, Freyschuss B, Vist G, et al. GRADE guidelines 6. Rating the quality of evidence—imprecision. J Clin Epidemiol. 2011;64(12):1283–1293. PubMed| CrossRef
- Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, Alonso-Coello P, Glasziou P, Jaeschke R, Akl EA, et al. GRADE guidelines: 7. Rating the quality of evidence—inconsistency. J Clin Epidemiol. 2011;64(12):1294–1302. PubMed| CrossRef
- Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, Alonso-Coello P, Falck-Ytter Y, Jaeschke R, Vist G, et al. GRADE guidelines: 8. Rating the quality of evidence–indirectness. J Clin Epidemiol. 2011;64(12):1303–1310. PubMed| CrossRef
- Guyatt GH, Oxman AD, Sultan S, Glasziou P, Akl EA, Alonso-Coello P, Atkins D, Kunz R, Brozek J, Montori V, et al. GRADE guidelines: 9. Rating up the quality of evidence. J Clin Epidemiol. 2011;64(12):1311–1316. PubMed| CrossRef
- Guyatt GH, Oxman AD, Schünemann HJ. GRADE guidelines—an introduction to the 10th-13th articles in the series. J Clin Epidemiol. 2013;66(2):121–123. PubMed| CrossRef
- Brunetti M, Shemilt I, Pregno S, Vale L, Oxman AD, Lord J, Sisk J, Ruiz F, Hill S, Guyatt GH, et al. GRADE guidelines: 10. Considering resource use and rating the quality of economic evidence. J Clin Epidemiol. 2013;66(2):140–150. PubMed| CrossRef
- Guyatt G, Oxman AD, Sultan S, Brozek J, Glasziou P, Alonso-Coello P, Atkins D, Kunz R, Montori V, Jaeschke R, et al. GRADE guidelines: 11. Making an overall rating of confidence in effect estimates for a single outcome and for all outcomes. J Clin Epidemiol. 2013;66(2):151–157. PubMed| CrossRef
- Guyatt GH, Oxman AD, Santesso N, Helfand M, Vist G, Kunz R, Brozek J, Norris S, Meerpohl J, Djulbegovic B, et al. GRADE guidelines: 12. Preparing summary of findings tables-binary outcomes. J Clin Epidemiol. 2013;66(2):158–172. PubMed| CrossRef
- Guyatt GH, Thorlund K, Oxman AD, Walter SD, Patrick D, Furukawa TA, Johnston BC, Karanicolas P, Akl EA, Vist G, et al. GRADE guidelines: 13. Preparing summary of findings tables and evidence profiles-continuous outcomes. J Clin Epidemiol. 2013;66(2):173–183. PubMed| CrossRef
- Andrews J, Guyatt G, Oxman AD, Alderson P, Dahm P, Falck-Ytter Y, Nasser M, Meerpohl J, Post PN, Kunz R, et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol. 2013;66(7):719–725. PubMed| CrossRef
- Andrews JC, Schünemann HJ, Oxman AD, Pottie K, Meerpohl JJ, Coello PA, Rind D, Montori VM, Brito JP, Norris S, et al. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation's direction and strength. J Clin Epidemiol. 2013;66(7):726–735. PubMed| CrossRef
- Gonzalez RP, Falimirski ME, Holevar MR. Further evaluation of colostomy in penetrating colon injury. Am Surg. 2000;66(4):342–347. PubMed
- Kamwendo NY, Modiba MC, Matlala NS, Becker PJ. Randomized clinical trial to determine if delay from time of penetrating colonic injury precludes primary repair. Br J Surg. 2002;89(8):993–998. View Full Text| PubMed| CrossRef
- Nelson RL, Singer M. Primary repair for penetrating colon injuries (review). Cochrane Library. 2009;4: doi: 10.1002/14651858.CD002247.
- Miller PR, Fabian TC, Croce MA, Magnotti LJ, Elizabeth Pritchard F, Minard G, Stewart RM. Improving outcomes following penetrating colon wounds: application of a clinical pathway. Ann Surg. 2002;235(6):775–781. View Full Text| PubMed| CrossRef
- Fealk M, Osipov R, Foster K, Caruso D, Kassir A. The conundrum of traumatic colon injury. Am J Surg. 2004;188(6):663–670. PubMed| CrossRef
- Mihmanli M, Erzurumlu K, Güney M. Primary repairing in penetrating colon injuries. Hepatogastroenterology. 1996;43(10):819–822. PubMed
- Kuzma J, Jaworski J. Primary repair of colonic injuries at the Kundiawa and Madang General Hospitals, Papua New Guinea. P N G Med J. 2008;51(1–2):43–46. PubMed
- Cornwell EE 3rd, Velmahos GC, Berne TV, Murray JA, Chahwan S, Asensio J, Demetriades D. The fate of colonic suture lines in high-risk trauma patients: a prospective analysis. J Am Coll Surg. 1998;187(1):58–63. PubMed| CrossRef
- Murray JA, Demetriades D, Colson M, Song Z, Velmahos GC, Cornwell EE 3rd, Asensio JA, Belzberg H, Berne TV. Colonic resection in trauma: Colostomy versus anastomosis. J Trauma. 1999;46(2):250–254. View Full Text| PubMed| CrossRef
- Flint LM, Vitale GC, Richardson JD, Polk HC Jr. The injured colon: relationships of management to complications. Ann Surg. 1981;193(5):619–623. View Full Text| PubMed| CrossRef
- Demetriades D, Murray JA, Chan L, Ordoñez C, Bowley D, Nagy KK, Cornwell EE 3rd, Velmahos GC, Muñoz N, Hatzitheofilou C, et al. Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma. 2001;50(5):765–775. View Full Text| PubMed| CrossRef
- Steel M, Danne P, Jones I. Colon trauma: Royal Melbourne Hospital experience. ANZ J Surg. 2002;72(5):357–359. View Full Text| PubMed| CrossRef
- Sambasivan CN, Underwood SJ, Kuehn RB, Cho SD, Kiraly LN, Hamilton GJ, Flaherty SF, Dorlac WC, Schreiber MA. Management and outcomes of traumatic colon injury in civilian and military patients. Am Surg. 2011;77(12):1685–1691. PubMed
- Adesanya AA, Ekanem EE. A ten-year study of penetrating injuries of the colon. Dis Colon Rectum. 2004;47(12):2169–2177. View Full Text| PubMed| CrossRef
- Girgin S, Gedik E, Uysal E, Taçyildiz IH. Independent risk factors of morbidity in penetrating colon injuries. Ulus Travma Acil Cerrahi Derg. 2009;15(3):232–238.
- Bulger EM, McMahon K, Jurkovich GJ. The morbidity of penetrating colon injury. Injury. 2003;34(1):41–46. PubMed| CrossRef
- Behrman SW, Bertken KA, Stefanacci HA, Parks SN. Breakdown of intestinal repair after laparotomy for trauma: incidence, risk factors, and strategies for prevention. J Trauma. 1998;45(2):227–233. View Full Text| PubMed| CrossRef
- Schnüriger B, Inaba K, Wu T, Eberle BM, Belzberg H, Demetriades D. Crystalloids after primary colon resection and anastomosis at initial trauma laparotomy: excessive volumes are associated with anastomotic leakage. J Trauma. 2011;70(3):603–610. View Full Text| PubMed| CrossRef
- Torba M, Gjata A, Buci S, Bushi G, Zenelaj A, Kajo I, Koceku S, Kagjini K, Subashi K. The influence of the risk factor on the abdominal complications in colon injury management. G Chir. 2015;36(2):57–62. PubMed
- Conrad JK, Ferry KM, Foreman ML, Gogel BM, Fisher TL, Livingston SA. Changing management trends in penetrating colon trauma. Dis Colon Rectum. 2000;43(4):466–471. View Full Text| PubMed| CrossRef
- Sharpe JP, Magnotti LJ, Weinberg JA, Parks NA, Maish GO, Shahan CP, Fabian TC, Croce MA. Adherence to a simplified management algorithm reduces morbidity and mortality after penetrating colon injuries: a 15-year experience. J Am Coll Surg. 2012;214(4):591–598. PubMed
- Oztürk G, Aydinli B, Selcuk Atamanalp S, Celebi F, Ilhan Yildirgan M, Donmez R. Penetrating colon injury: experience of a single centre. Acta Chir Belg. 2009;109(2):185–190. View Full Text| PubMed| CrossRef
- Dente CJ, Tyburski J, Wilson RF, Collinge J, Steffes C, Carlin A. Ostomy as a risk factor for posttraumatic infection in penetrating colonic injuries: univariate and multivariate analyses. J Trauma. 2000;49(4):628–637. View Full Text| PubMed| CrossRef
- Durham RM, Pruitt C, Moran J, Longo WE. Civilian colon trauma: factors that predict success by primary repair. Dis Colon Rectum. 1997;40(6):685–692. View Full Text| PubMed| CrossRef
- Chavarria-Aguilar M, Cockerham WT, Barker DE, Ciraulo DL, Richart CM, Maxwell RA. Management of destructive bowel injury in the open abdomen. J Trauma. 2004;56(3):560–564. View Full Text| PubMed| CrossRef
- Johnson JW, Gracias VH, Schwab CW, Reilly PM, Kauder DR, Shapiro MB, Dabrowski GP, Rotondo MF. Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma. 2001;51(2):261–271. View Full Text| PubMed| CrossRef
- Miller PR, Chang MC, Hoth JJ, Holmes JH 4th, Meredith JW. Colonic resection in the setting of damage control laparotomy: is delayed anastomosis safe? Am Surg. 2007;73(6):606–610. PubMed
- Ordoñez CA, Pino LF, Badiel M, Sánchez AI, Loaiza J, Ballestas L, Puyana JC. Safety of performing a delayed anastomosis during damage control laparotomy in patients with destructive colon injuries. J Trauma. 2011;71(6):1512–1518. View Full Text| PubMed| CrossRef
- Ott MM, Norris PR, Diaz JJ, Collier BR, Jenkins JM, Gunter OL, Morris JA Jr. Colon anastomosis after damage control laparotomy: recommendations from 174 trauma colectomies. J Trauma. 2011;70(3):595–602. View Full Text| PubMed| CrossRef
- Weinberg JA, Griffin RL, Vandromme MJ, Melton SM, George RL, Reiff DA, Kerby JD, Rue LW 3rd. Management of colon wounds in the setting of damage control laparotomy: a cautionary tale. J Trauma. 2009;67(5):929–935. View Full Text| PubMed| CrossRef
- Burlew CC, Moore EE, Cuschieri J, Jurkovich GJ, Codner P, Crowell K, Nirula R, Haan J, Rowell SE, Kato CM, et al. Sew it up! A Western Trauma Association multi-institutional study of enteric injury management in the postinjury open abdomen. J Trauma. 2011;70(2):273–277. View Full Text| PubMed| CrossRef
- Kashuk JL, Cothren CC, Moore EE, Johnson JL, Biffl WL, Barnett CC. Primary repair of civilian colon injuries is safe in the damage control scenario. Surgery. 2009;146(4):663–670. View Full Text| PubMed| CrossRef
- Tatebe LC, Jennings A, Tatebe K, Handy A, Prajapati P, Smith M, Do T, Ogola GO, Gandhi RR, Duane TM, et al. Traumatic colon injury in damage control laparotomy—A multicenter trial: is it safe to do a delayed anastomosis? J Trauma Acute Care Surg. 2017;82(4):742–749.
- Anjaria DJ, Ullmann TM, Lavery RL, Livingston DH. Management of colonic injuries in the setting of damage-control laparotomy: one shot to get it right. J Trauma Acute Care Surg. 2014;76(3):594–600.
- Georgoff P, Perales P, Laguna B, Holena D, Reilly P, Sims C. Colonic injuries and the damage control abdomen: does management strategy matter? J Surg Res. 2013;181(2):293–299. PubMed| CrossRef
Colon injury; colon trauma; colon repair; penetrating abdominal trauma; damage control surgery